Managing intravascular complications following treatment with calcium hydroxylapatite: An expert consensus

Abstract

Background Inadvertent intra‐arterial injection of dermal fillers including calcium hydroxylapatite (CaHA) can result in serious adverse events including soft tissue necrosis, permanent scarring, visual impairment, and blindness. When intra‐arterial injection occurs, immediate action is required for optimal outcomes, but the infrequency of this event means that many physicians may never have experienced this scenario. The aim of this document is to provide evidence‐based and expert opinion recommendations for the recognition and management of vascular compromise following inadvertent injection of CaHA. Methods An international group of experts with experience in injection of CaHA and management of vascular complications was convened to develop a consensus on the optimal management of vascular compromise following intra‐arterial CaHA injection. The consensus members were asked to provide preventative advice for the avoidance of intravascular injection and to produce a treatment protocol for acute and delayed presentation. To ensure all relevant treatment options were included, the recommendations were supplemented with a PubMed search of the literature. Results For prevention of intra‐arterial CaHA injection, consensus members outlined the importance of a thorough knowledge of facial vascular anatomy and patient history, as well as highlighting potential risk zones and optimal injection techniques. Individual sections document how to recognize the symptoms of vascular occlusion leading to vision loss and tissue necrosis as well as detailed treatment protocols for the management of these events. For impending tissue necrosis, recommendations are provided for early and delayed presentations with treatment protocols for acute and follow‐up treatment. A separate section details the treatment options for open and closed wounds. Conclusions All physicians should be prepared for the eventuality of intra‐arterial injection of a dermal filler, despite its rarity. These consensus recommendations combine advice from aesthetic experts with the latest reports from the published literature to provide an up‐to‐date office‐based protocol for the prevention and treatment of complications arising from intra‐arterial CaHA injection.

Can Sodium Thiosulfate Act as a Reversal Agent for Calcium Hydroxylapatite Filler? Results of a Preclinical Study

“…[3][4][5][6][7][8] For personnel performing aesthetic filler injections, it is important to have clear guidance on the prevention and treatment of potential complications. 9,10 For HA fillers, hyaluronidase is utilized as a reversal agent. 11 In addition, there is interest in identifying a compound that can dissolve CaHA to address over-correction or nodule formation and reversal of vascular occlusions.…”

“…11 In addition, there is interest in identifying a compound that can dissolve CaHA to address over-correction or nodule formation and reversal of vascular occlusions. 9,10,12,13 Sodium thiosulfate (STS) was considered as a CaHA reversal agent candidate due to its action as a chelating agent shown to successfully treat calciphylaxis. 14,15 Preliminary preclinical in vitro and in vivo studies suggest STS may produce degradation of CaHA particles.…”

“… 11 In addition, there is interest in identifying a compound that can dissolve CaHA to address over-correction or nodule formation and reversal of vascular occlusions. 9 , 10 , 12 , 13…”

Saline in dermatologic surgery

“…Hydrodissection has also been used to assist safe injections of calcium hydroxylapatite fillers in the forehead, 6 with the use of a tumescent solution purported to generate a space for the filler, while also reducing bleeding. 7 In summary, saline has an important role as a LA, for tumescent anesthesia and for hydrodissection among its other uses in dermatologic practice.…”

Design and Fabrication of a Hierarchically Structured Scaffold for Tendon‐to‐Bone Repair

“…[2] Here we report the design, fabrication, and evaluation of a hierarchically structured scaffold that recapitulates anatomic structure of the tendon-to-bone attachment site (Scheme 1). Two FDA-approved materials, hydroxyapatite (HAp) [20] and poly(lactic- co -glycolic acid) (PLGA), [21] were used to construct the scaffold. To create a porous, rigid structure comparable to trabecular bone, HAp/PLGA composite was infiltrated into the void space among gelatin beads ( ca.…”